abdominal examination.2
TRANSCRIPT
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PEMERIKSAAN ABDOMEN
Dr. SUHAEMI, SpPD, Finasim
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General principles of exam
Abdominal Examination
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The History and Physical in
Perspective
70% of diagnoses can be made based onhistory alone.
90% of diagnoses can be made based on
history and physical exam.Expensive tests often confirm what isfound during the history and physical.
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Equipment for physical examination
RequiredStethoscope
Tongue blades
Penlight
Tape measure
Sphygmomanometer
Reflex hammerSafety pins
Optional
Gloves
Gauze pads
Lubricant gel
Nasal speculum
Turning fork: 128 Hz,512Hz
Pocket visual acuitycard
Oto-ophthalmoscope
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Important aspects of physical
examination----physicianElegant appearance
Decent manner
Kind attitude
Highly responsibility
Good medical
morals
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Important aspects of physical
examination---physicianWash your hands,preferably while thepatient is watching
Washing with soapand water is aneffective way to
reduce thetransmission ofdisease
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How to perform the physical
examination?
Exposing only the
area that are being
examined
Offer a chaperone forboth sexes.
Explain what you're
going to do
Sequential
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Important aspects of physical
examinationThe examiner shouldcontinue speaking tothe patient
Showing care to hisdisease and answer topatients questions
It can not only releasepatients nerviness, butalso help to establishthe good physician-patient relationship
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Gloves should be worn when..
Examining any
individual with
exudative lesions or
weeping dermatitisWhen handling
blood-soiled orbody
fluid-soiled sheets
or clothing
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General principles of exam
Good light
Relaxedpatient
Full exposure
of abdomen
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General principles of exam
Have the patient
empty their bladder
before examination
Have the patient lie ina comfortable, flat,
supine position
Have them keep their
arms at their sides or
folded on the chest
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General principles of exam
Before the exam, ask
the patient to identify
painful areas so that
you can examinethose areas last
During the exam pay
attention to theirfacial
expression to assessfor sign of discomfort
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General principles of exam
Use warm hand,
warm stethoscope,
and have short finger
nailsApproach the patient
slowly and
deliberately
explaining what youwill be doing
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General principles of exam
Stand right side of thebed
Exam with right handHead just a littleelevated
Ask the patient to
keep the mouthpartially open andbreathe gently
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General principles of exam
If muscles remain
tense, patient may
be asked to restfeet on table with
hips and knees
flexed
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Other helpful points on examination
Take a spare bed
sheet and drape it
over their lower bodysuch that it just
covers the upper
edge of their
underwear
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General principles of exam
If the patient is ticklishor frightened
Initially use the
patients hand underyours as you palpate
When patient calmsthen use your hands
to palpate.Watch the patientsface for discomfort.
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Think
Anatomically
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Think Anatomically
When looking,
listening, feeling and
percussing imagine
what organs live inthe area that you are
examining.
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Right Upper Quadrant (RUQ)
liver, gallbladder,
duodenum,
right kidneyand hepatic
flexure of colon
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Right Lower Quadrant (RLQ)
Cecum,
appendix (in
case of female,right ovary &
tube)
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Left Lower Quadrant (LLQ)
Sigmoid
colon (in case
of female, leftovary & tube)
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Left Upper Quadrant (LUQ)
Stomach,
spleen, left
kidney, pancreas(tail), splenic
flexure of colon
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Epigastric Area
Stomach,
pancreas
(head andbody), aorta
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Landmarks of the abdominal wall,
Costal margin,
umbilicus, iliac crest,
anterior superior iliac
spine, symphysispubis, pubic tubercle,
inguinal ligament,
rectus abdominis
muscle, xiphoidprocess.
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Physical Examination of the
Abdomen
Inspection
Auscultation
PercussionPalpation
Special Tests
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Inspection
Abdominal examination
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Appearance of the abdomen
Is Aortic pulsation?
Is it flat orScaphoid
(Normally)?Distended?
If enlarged, does this
appearsymmetric?With bulging or
moving?
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Symmetrical in shape
Scaphoid or flat in young
patients of normal weight
slightly full but not distended in older age
group due to poor muscle tone or in
subjects who are mildly overweight
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Appreciation of abdominal contours
Standing at the foot ofthe table and looking uptowards the patient'shead.
Lower yourself until the
anterior abdominalwall and ask the patientto breathe normally while
you are doing so.
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Appearance of the abdomen
Global
abdominalenlargement is
usually caused
by air, fluid, orfat.
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Appearance of the abdomen
Localized
enlargementprobably distend
GB space
occupying lesion,hepatomegaly.
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An aortic aneurysm
Palpable mass
Patient feeling of
pulsation
On rare occasions, alump can be visible.
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An aortic aneurysm
1 in 10 men over 65
may have some
enlargement of the
abdominal aorta.About 1 in 100 will
have a large
aneurysm requiring
surgery.
Appearance of the abdomen
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Appearance of the abdomen
(Skin)
Abnormal venouspatterns
Abnormal
discoloration
Umbilicus issunken
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Striae
Stretch marks are a
light silver hue.
Pregnancy and obese
individualsCushings syndrome
(more purple or pink).
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Appearance of the abdomen
(Skin)
TattoosScars can be drawn
on schematic
diagrams of theabdomen (a picture is
worth a thousand
words).
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Cullens sign
Ecchymosis
periumbilically.
(intraperitonealhemorrhage
ruptured ectopic
pregnancy,hemorrhagic
pancreatitis..)
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Grey-Turners sign
Ecchymosis of
flanks.
(retroperitonealhemorrhage
such as
hemorrhagicpancreatitis)
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Upward flow direction indicates IVC obstruction
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Outward flow pattern from umbilicus in all directions ? Portal HTN
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Evaluate venous return states
Place index finger
side by side over a
vein and press
laterally, milking vein.Release one finger
and time refill, repeat
with other finger.
Venous return is indirection of faster
filling.
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Appearance of the abdomen
Areas which
become more
pronounced when
the patientvalsalvas areoften associated
with ventralhernias
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Visible Pulsations
More conspicuous in the
thin than in the fat
Greater in the old than in
the young.
Increased in
thyrotoxicosis,
hypertension, or aortic
regurgitation)
In those with an aortic
aneurysm and tortuous
aorta
In those who have a
mass joining the aorta tothe anterior abdominal
wall.
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Visible gastric Peristalsis
Gastric peristalsis is
commonly seen in
neonates with
congenitalhypertrophic pyloric
stenosis
Intestinal peristalsis in
partial and chronic
intestinal obstruction
Colonic obstruction isusually not manifest
as visible peristalsis
Visible intestinal Peristalsis
A f th bd
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Appearance of the abdomen
Patient's movement
Patients with kidney
stones will frequently
writhe on theexamination table,
unable to find a
comfortable
position
A f th bd
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Appearance of the abdomen
Patient's movement
Patients with
peritonitis prefer to lie
very still as anymotion causes further
peritoneal irritation
and pain.
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Auscultation
Abdominal examination
A lt ti
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Auscultation
Bowel sounds
Vascularsounds (bruits)
Friction Rubs
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Auscultation for bowel sounds
It is performed before percussion or
palpation
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Auscultation for bowel sounds
Normal sounds are
due to peristaltic
activity.Peristalsis: A
pregressice wavelike
movement that occurs
involuntarily in hollowtubes of the body.
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Auscultation for bowel sounds
Compared to the
cardiac and
pulmonary exams,auscultation of the
abdomen has a
relatively minor role.
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Auscultation for bowel sounds
Bowel sounds lend
supporting
information to otherfindings but are not
pathognomonicfor any particular
process.
A sc ltation
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Auscultation
1.Diaphragm of
stethoscope
used
2.Skin
depressed to
approximately 1cm
Auscultation
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Auscultation
3.Listening in one
spot is usually
sufficient
4.Listening for15-20or 30-60 seconds
5.Bowel sounds cannot
be said to be absent
unless they are not heardafter listening for3-5
minutes.
Three things about bowel
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Three things about bowel
soundAre bowel sounds
present?
If present, are they
frequent or sparse(i.e.quantity)?
What is the nature of
the sounds
(i.e.quality)?
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Bowel sound decrease
Inflammatory
processes of the
serosaAfter abdominal
surgery
In response to
narcotic analgesics or
anesthesia.
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Auscultation for bowel sounds
Inflammation of the
intestinal mucosa
will causehyperactive bowel
sounds.
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Auscultation for bowel sounds
Processes which
lead to intestinal
obstruction initially
cause frequentbowel sounds,
referred to as
"rushes."
Auscultation for bowel
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Auscultation for bowel
soundsProcesses which lead
to intestinal
obstruction initially
cause frequent bowelsounds, referred to as
"rushes."
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Auscultation for bowel sounds
Rushes" means
as the intestines
trying to force
their contents
through a tight
opening.
Auscultation for bowel
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Auscultation for bowel
soundsRushes" is followed
by decreased sound,
called "tinkles," and
then silence.
Auscultation for bowel
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Auscultation for bowel
soundsAftersilence the
appearance of bowel
sounds marks the
return of intestinalsounds activity, an
important phase of
the patient's recovery.
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Splash Sign
Splashing sound
indicative ofair or
fluid in body cavitywith shaking
individual: normal in s
stomach.
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Auscultation for bowel sounds
Bowel sounds,
then, must be
interpreted within
the context of the
particular clinical
situation.
Bruits
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Bruits
Bruits confined
to systole do notnecessarily
indicate disease.
Auscultation for vascular sounds
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Auscultation for vascular sounds
(bruits)
Aortic (midline betweenumbilicus and xiphoid
Renal (two inchessuperiorto and two
inches lateral toumbilicus)
Common iliac (midwaybetween umbilicusand midpoint ofinguinal ligament)
Auscultation for vascular sounds
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Auscultation for vascular sounds
(bruits)
Presence of a bruit
on the renal artery
would lendsupporting
evidence for the
existence ofrenalartery stenosis.
Auscultation for vascular sounds
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(bruits)
When listening forbruits, you will need
to press down quite
firmly as the renal
arteries are
retroperitoneal
structures.
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Venous Hum (rare)
Epigastric/umbilicalarea.
Soft humming noises
in systolic/diastoliccomponent.
Indicates collateral
between portal and
venous systems as inhepatic cirrhosis.
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RubsRubs-Rubs
Liver
SpleenCardiac
Pulmonary
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Friction rubs (rare)
Right and left upperquandrants
Grating sound withrespiratory movement
Indicatesinflammation of the
capsule of the liver orspleen (infection orinfarction).
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Percussion
Abdominal examination
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P i
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Percussion
Technique
LiverSpleen
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P i (t h i )
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Percussion (technique)
Striking hand
should move
only at the wrist,
with only little
more than force
of gravity
P i (t h i )
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Percussion (technique)
Middle fingerofstriking hand
(plexor) should
knock the
pleximeter firmly,
with a strong
note
There are two basic sounds with
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There are two basic sounds with
Percussion
Tympanitic(drum-like)
sounds
produced by
percussing over
air filled
structures.
There are two basic sounds with
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There are two basic sounds with
Percussion
Dull sounds that
occur when a solid
structure (e.g. liver)orfluid (e.g. ascites)
lies beneath the
region being
examined.
E i ti f Li (P i )
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Examination of Liver (Percussion)
Midclavicularline
is noted
Second
intercostal space
is noted
The two solid organs are
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e o so d o ga s a e
percussable in the normal patient
Liver: will be entirelycovered by the ribs.
Occasionally, an edge
may protrude 1-2
centimeter below the
costal margin.
Spleen: The spleen is
smaller and is entirelyprotected by the ribs.
T d t i th i f th li
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To determine the size of the liver
Measure the liverspan by percussing
hepatic dullness from
above (lung) and
below (bowel). A
normal liver span is 6
to 12 cm in the
midclavicular line.
T d t i th i f th li
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To determine the size of the liver
Start just below theright breast in a line
with the middle of
the clavicle.
Percussion in this
area should
produce a relatively
resonant note.
T d t i th i f th li
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To determine the size of the liver
Move your handdown a few
centimeters than
you will be overthe liver, which
will produce a
duller soundingtone.
To determine the si e of the li er
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To determine the size of the liver
Continuedownward until
the sound
changes onceagain. At this
point, you will
have reached theinferior margin of
the liver.
Examination of Liver (Percussion)
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Examination of Liver (Percussion)
Upper margin isnoted by first dull
percussion note
Lower margin isnoted by first
tympanitic note
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To determine the size of the
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liver
The resonant tone produced bypercussion over the anterior chest
wall will be somewhat less drum like
then that generated over the
intestines. While they are both
caused by tapping over air filled
structures, the ribs and pectoralis
muscle tend to dampen the sound.
Examination of Spleen
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p
(Percussion)
Percussion at Castells Spot
Castells Spot identified
Left anterior axillary line identified
Left lower costal margin identified
Percussion at Castells Spot while patient
inhales and exhales deeply
Dull tone indicates
possible splenomegaly
Spleen percussion
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Spleen percussion
Enlarged spleenproduce a dull
tone, in the left
upper quadrantpercussion but
should then be
verified bypalpation.
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Palpation
Abdominal examination
Abdominal Palpation
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Technique
Light
DeepLiver edge
Spleen tip
Kidneys
AortaMasses
Abdominal palpation
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Abdominal palpation
To palpate fourquadrants
superficially
from LLQcounterclockwise
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Light Palpation
Light Palpation
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Light Palpation
First warm yourhands by rubbing
them together before
placing them on the
patient.
Abdominal wall
depressed
approximately 1 cm
Abdominal palpation
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Abdominal palpation
Use pads of threefingers of one hand
and a light, gentle,
dippingmaneuverto
examine abdomen
Palpation (light)
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Palpation (light)
Any areas of pain ortenderness are
reserved for
evaluation at the end
of the exam
Light Palpation
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Light Palpation
Mostly looking forareas oftenderness
Tenderness is a
physical exam findinga reflex occurs
(muscle splinting,
wide eyes, moaning,
teeth gritting).
Palpation
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Light palpation assesses
Muscle toneCutaneous
hypersensitivity
(suggests peritoneal
irritation)
Palpation
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Light palpation assesses
Presence ofsuperficial
(intramural) masses is
more prominent if
patient raises their
head ,Intra-abdominal
mass is less
prominent if patientraises their head
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Deep Palpation
Palpation (deep)
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Entire palm
Either one- or
two handed
technique is
acceptable
Deep Palpation
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Deep Palpation
Use palmar surface offingers of one hand
(greatest number of
fingers) and a deep,
firm, gentle maneuver
to examine abdomen
Palpation
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Palpation
Palpate deeply with
finger pads (do not
dig in with fingertips)
Deep Palpation
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Deep Palpation
Palpate tender areaslast
Try to identify
abdominal masses or
areas ofdeep
tenderness
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Two handed technique
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Two handed technique
When deeppalpation is difficult,
examiner may
want to use lefthand placed over
right hand to help
exert pressure
Palpation (deep)
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Push as deeply aspatient will allow
without significant
discomfort
Normal structure that may be
l bl
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palpable
Sigmoid colon
Liver
Kidney
Abdominal aorta
Iliac artery
Distended bladder
Gravid and non-
gravid uterus
Xyphoid processspleen
Abdominal mass
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Abdominal mass
Intra abdominalmasses or
enlargements of the
liver, gallbladder or
spleen
Abdominal wall mass
Intra abdominal masses or enlargements of
th li llbl dd l
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the liver, gallbladder or spleen
They will shift downwith inspiration and
back with expiration.
(not true of masses
within the abdominalwall orretroperitoneal
structures).
Aabdominal wall mass
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Aabdominal wall mass
It will become moreevident and palpable
when patient flexes
neck as this contracts
rectus muscles.
Paraumbilical node
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Paraumbilical node
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Abdominal pain andTenderness
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Type of abdominal pain
Visceral pain Somatic pain
Visceral pain
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Visceral pain
This is pain thatarises from an
organic lesion or
functional disturbance
within an abdominalviscus (dull,poorly
localized, and difficult
for the patient to
characterize).
Somatic pain
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Somatic pain
Painful lesion of theskin
Sharp, bright, andwell localized
Indicatesinvolvement ofparietal peritoneumor the abdominal
wall itself
Tenderness
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Tenderness
If there is tendernessdetermine the point of
maximum tenderness
and its distribution
Abdominal muscle spasm
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p
Voluntary guardingTensing abdominalmuscles due topatient anxiety,
ticklishness, ortoprevent palpation toa painful area
Involuntary guardingMuscular spasm or
rigidity due toperitoneal
inflammationMay be localized(early appendicitis )ordiffuse (perforated
bowel)
Board-like rigidity
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Board like rigidity
If abdominal wall ispalpated as obviously
tense, even as rigid
as a board, board-like
rigidity is so called. Iscaused by the spasm
of abdominal muscle
due to peritoneal
irritation.
Differential diagnosis of abdominal
pain
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pain
Spine painAbdominal wall
pain( differentiated by
having the patient
tense his abdominal
muscles, by forcefully
elevating his head
while keeping hisshoulders flat on the
table)
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Liver palpation
Liver palpation
(St d d M th d)
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(Standard Method)
Start in the RUQ,10centimeters below the
rib margin in the mid-
clavicular line
Place left hand
posteriorly parallel to
and supporting 11th &
12th ribs on right.
Standard Method Liver palpation
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p p
Ask the patient to
take a deep breath.
You may feel theedge of the liver press
against your fingers.
Liver palpation
(St d d M th d)
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133/179
(Standard Method)
Palpating hand is
held steady while
patient inhales
Liver palpation
(St d d M th d)
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134/179
(Standard Method)
Palpating hand islifted and moved
while the patient
breathes out
Liver palpation
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135/179
Another method ofpalpating the liveruses the radial borderof the index finger. In
this method theanterior hand isplaced flat on theanterior abdominal
wall with fingersparallel to the costalmargin
Alternate Method Liver palpation
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136/179
Is useful when the
patient is obese or
when the examineris small compared
to the patient.
Alternate Method Liver palpation
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137/179
Stand by the patient'schest.
"Hook" your fingers
just below the costal
margin and press
firmly.
Hepatomegaly
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138/179
g y
More than 1cm belowthe costal margin
An exception is a
congenitally large
right lobe of the liver
Severe, chronic
emphysema
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139/179
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140/179
Pulsation transmitted from aorta Tricuspid valve insufficiency
Hepatojugular reflux sign
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141/179
If you press the liver,you will find thedilated jugular veinbecomes more
bulged or distended,as from theenlargement of liverpassive congestionresulted from rightfailure.
Ballotable sign
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142/179
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7/27/2019 Abdominal Examination.2
143/179
-
7/27/2019 Abdominal Examination.2
144/179
Spleen palpation
Spleen palpation
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145/179
Seldom palpable innormal adults.
Causes include
COPD, and deep
inspiratory descent ofthe diaphragm.
Spleen palpation
-
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146/179
Support lower left ribcage with left hand
while patient is supine
and lift anteriorly on
the rib cage.
Spleen palpation
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147/179
Palpate upwardstoward spleen with
finger tips of right
hand, starting below
left costal margin.
Have the patient take
a deep breath.
Examination of Spleen
(Palpation)
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148/179
(Palpation)
Deep technique used
Starting point is RLQ,proceeding to LUQ
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149/179
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7/27/2019 Abdominal Examination.2
150/179
-
7/27/2019 Abdominal Examination.2
151/179
Kidney palpation
Kidney palpation
-
7/27/2019 Abdominal Examination.2
152/179
Place left handposteriorly just below
the right 12th rib. Lift
upwards.
Palpate deeply with
right hand on anterior
abdominal wall.
Examination of Kidney
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153/179
Patient take a deepbreath.
Feel lower pole of
kidney and try to
capture it between
your hands.
Examination of Kidney
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154/179
Right kidney may be felt to slip between hands
during exhalation
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155/179
Palpation of the Aorta
Examination of Aorta
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156/179
Flat palm placed
over the theepigastrium to
locate pulse
Examination of Aorta
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157/179
Press down deeply inthe midline above the
umbilicus.
The aortic pulsation is
easily felt on most
individuals.
Examination of Aorta
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158/179
Hands then oriented
vertically on either
side of midline with
distal fingers at level
of pulsation; equal
pressure applied until
pulsation is palpated
A well defined, pulsatile mass, greater than
cm across, suggests an aortic aneurysm.
Examination of Aorta
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159/179
Lateral width of pulsation is determined by
space between index fingers
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160/179
Special exam
Abdominal examination
Special exam
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161/179
Murphys SignMcBurneysPoint
Rovsings SignPsoas Sign
ObturatorSign
Re boundTenderness
Costovertebral
tenderness
Shifting
DullnessFluid wave
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162/179
McBurneys Point
-
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163/179
Localized tendernessJust below midpoint
of line between right
anterior iliac crest and
umbilicus.Heel strike, riding
over bumps in road
while driving,
coughing, will
produce pain.
McBurneys Point (Common Causes)
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164/179
AppendicitisIncarcerated orstrangulated hernia
Ovarian torsion (twistedFallopian tube)
Pelvic inflammatorydisease
Abdominal abscess
Hepatitis
Diverticular diseaseMeckel''s diverticulum
Rovsings Sign
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7/27/2019 Abdominal Examination.2
165/179
Patient will
experience right lower
quadrant pain (in
region of McBurneysPoint) when left lower
quadrant is palpated.
Non-Classical Appendicitis
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166/179
Iliopsoas Sign
Obturator Sign
Iliopsoas Sign
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167/179
Patient can lay on side and extend leg at the hip
or have patient lay on back and try to flex hip
against the resistance of examiners hand on
thigh. If patient has an inflamed retrocecal
appendix this will produce pain
Iliopsoas Sign
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168/179
Anatomic basis forthe psoas sign:
inflamed appendix is
in a retroperitoneal
location in contactwith the psoas
muscle, which is
stretched by this
maneuver.
Obturator Sign
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169/179
Internally rotate right leg at the hip with the knee
at 90 degrees of flexion. Will produce pain if
Obturator Sign
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170/179
Anatomic basis forthe obturator sign:
inflamed appendix in
the pelvis is in contact
with the obturatorinternus muscle,
which is stretched by
this maneuver.
Rebound Tenderness
(For peritoneal irritation)
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171/179
Warn the patient what
you are about to do.
Press deeply on the
abdomen with your hand.After a moment, quickly
release pressure.
If it hurts more when you
release, the patient hasrebound tenderness. [4]
Cost vertebral Tenderness
(Often with renal disease)
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172/179
Use the heel of yourclosed fist to strike
the patient firmly
over the
costovertebralangles.
Compare the left
and right sides.
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173/179
Warn the patient Patient sit up on the exam table
Shifting Dullness
(For peritoneal fluid)
-
7/27/2019 Abdominal Examination.2
174/179
Percuss from anterior
abdomen laterally to
outline areas of
dullness noted
Examination for ShiftingDullness
-
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175/179
Patient rolled slightlytoward the examined
side; movement of the
dull point medially is
described as shiftingdullness and
suggests ascites
-
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176/179
Shifting Dullness
-
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177/179
Fluid wave
-
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178/179
-
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179/179